Warning against overuse of drugs for inattentive children

BMJ 1996; 313 doi: (Published 28 September 1996) Cite this as: BMJ 1996;313:770

A report from a working party of the British Psychological Society published last week is calling for caution in the apparent rush to label naughty, inattentive children as having attention deficit hyperactivity disorder, and it warns against the overuse of drug treatment.

The diagnostic category of attention deficit hyperactivity disorder originates in the United States and includes children who are overactive, restless, impulsive, and inattentive to an extent which causes serious concern. There has been a noticeable increase in the numbers of cases being identified in the US and Canada over the past few years. In Europe and the United Kingdom such children have previously been termed hyperkinetic or hyperactive, but the disorder is now attracting a lot of public attention in the UK.

The report argues that the concept of the disorder is still evolving, with many theoretical and practical questions yet to be answered. “The concept of attention deficit hyperactivity disorder as a unitary condition is controversial for many reasons,” warned Dr Rea Reason, chair of the working party and lecturer in special education at the University of Manchester. “Attentional problems seem to be underpinned by an inability to maintain effort over time in order to meet task demands,” she explains. However, maintenance of effort seems to be influenced by a combination of biological, neurological, psychological, and environmental factors.

All possible factors, including environmental issues, parenting, and possible abuse, should be considered before suggesting a child has a neurological condition that may explain behavioural problems, argues the working party. Research suggests that only a small minority of children have problems with activity, attention, and impulsivity due to severe neurological damage. “Everyday manifestations of overactivity, impulsivity, and inattention do not necessarily imply the existence of this disorder,” warned Dr Reason. She suggests that great care must be taken before labelling children, which may have profound implications for their self image and the way they are treated by others.


Lack of concentration does not necessarily imply a child has attention deficit hyperactivity disorder

Eric Taylor, professor of developmental neuropsychiatry at the Medical Research Council's child psychiatry unit, welcomed the recommendations. “They support conventional wisdom on the management of attention deficit in the UK—individualised assessment and treatment of each child.”

The report calls for a multidisciplinary approach to the management of children with behavioural and attention problems. It recommends that educational, behavioural, parental, and medical interventions should be tailored to each child. “However we define attention problems, children, parents, and teachers need appropriate help,” said Dr Reason.

The report also calls for caution over drug treatment. “There is no doubt that psycho-stimulants such as Ritalin [methylphenidate hydrochloride] can be effective in attention deficit hyperactivity disorder. But the drug will also improve concentration in those who do not have the condition,” explained Dr Reason. She said that research had shown that a group of boys without behavioural problems were able to concentrate better and work for longer after being given methylphenidate hydrochloride. However, they exhibited rebound hyperactivity when the drug was stopped. “There have been some reports of apparently irresponsible prescribing of this drug,” she warned.

Dr Reason suggested that modifying a child's behaviour with drug treatment may give them the impression that this is the only way to control their actions. “There is also a wider ethical issue. Where do we draw the line for children who might benefit from drug treatment to improve concentration?” she added.—SUSAN MAYOR, medical journalist, London